What is the evidence on the economic impacts of integrated care?

This new policy summary reviews the existing evidence on the economic impact of integrated care approaches. Whereas it is generally accepted that integrated care models have a positive effect on the quality of care, health outcomes and patient satisfaction, it is less clear how cost effective they are. As the evidence-base in this field is rather weak, the authors suggest that we may have to revisit our understanding of the concept and our expectations in terms of its assessment. Integrated care should rather be seen as a complex strategy to innovate and implement long-lasting change in the way services in the health and social-care sectors are delivered. This policy summary (number 11) is based on a report for the European Commission to inform the discussions of the EU’s Reflection process on modern, responsive and sustainable health systems on the objective of integrated care models and better hospital management. Both authors are affiliated to RAND Europe

The economics of health

This report presents results from the Economics of Health project funded by the East Midlands Development Agency. The work was undertaken between November 2007 and February 2008. The main aim of the project was to examine the relationship between mental and physical health and employability, labour market participation and economic performance, with specific attention given to the direction of causal relationships

Overseas GP recruitment: comparing international GP training with the UK and ensuring that registration standards and patient safety are maintained

This is the final version. Available from Royal College of General Practitioners via the DOI in this record.Background Ambitious overseas recruitment targets have been set by the UK government to help alleviate the current GP shortage. European Economic Area (EEA) doctors can join the UK’s GP register under European law. Non-EEA doctors must obtain a Certificate of Eligibility for General Practice Registration (CEGPR), demonstrating equivalence to UK-trained doctors. CEGPR applications can be time-consuming and burdensome. To meet overseas recruitment targets, it is important to facilitate the most efficient route into UK general practice while maintaining registration standards and patient safety. Aim To develop a methodology to map postgraduate GP training and healthcare contextual data from an overseas country to the UK. Design & setting Desk-based research and stakeholder interviews. Method Four stages were undertaken: 1) developing a data collection template; 2) conducting a case study (using Australia as a test case); 3) refining the data collection template; and 4) creating a mapping framework. The case study used the 2016 curricula for the UK and Australia. Results Five ‘domains’ were identified: healthcare context, training pathway, curriculum, assessment, and continuing professional development (CPD) and revalidation. The final data collection template comprised 49 mapping items across the domains. The methodology incorporated the application of a red, amber, or green (RAG) rating to indicate similarity of data across the five domains. Australia was rated ‘green’ for training pathway, curriculum, and assessment, and ‘amber’ for healthcare context and CPD and revalidation. The overall rating was ‘green’. Conclusion Implementing this systematic methodology for mapping GP training between countries may support the UK’s ambitions to recruit more GPs, and alleviate current GP workforce pressures.NHS Englan

Improving the effectiveness and efficiency of outpatient services: A scoping review of interventions at the primary-secondary care interface

This is the final published version. Available from SAGE Publications via the DOI in this record.Objectives: Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services. Methods: A scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour. Results: The 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness. Conclusions: There are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians’skills through education or joint consultations with complex patients.National Institute for Health Research (NIHR

Communicating antimicrobial resistance: the need to go beyond human health

This is the final version. Available on open access from Oxford University Press via the DOI in this recor

Outpatient services and primary care: scoping review, substudies and international comparisons

This is the final version of the report. Available from the publisher via the DOI in this record.AIM: This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B. Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services. FINDINGS FROM THE SCOPING REVIEW: Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals. FINDINGS FROM THE SUBSTUDIES: Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS. CONCLUSIONS: For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.The NIHR Health Services and Delivery Research programme

Qualitative study of patient views on a 'telephone-first' approach in general practice in England: speaking to the GP by telephone before making face-to-face appointments.

This is the final version. Available from BMJ Publishing Group via the DOI in this record.OBJECTIVE: To understand patients' views on a 'telephone-first' approach, in which all appointment requests in general practice are followed by a telephone call from the general practitioner (GP). DESIGN: Qualitative interviews with patients and carers. SETTING: Twelve general practices in England. PARTICIPANTS: 43 patients, including 30 women, nine aged over 75 years, four parents of young children, five carers, five patients with hearing impairment and two whose first language was not English. RESULTS: Patients expressed varied views, often strongly held, ranging from enthusiasm for to hostility towards the 'telephone-first' approach. The new system suited some patients, avoiding the need to come into the surgery but was problematic for others, for example, when it was difficult for someone working in an open plan office to take a call-back. A substantial proportion of negative comments were about the operation of the scheme itself rather than the principles behind it, for example, difficulty getting through on the phone or being unable to schedule when the GP would phone back. Some practices were able to operate the scheme in a way that met their patients' needs better than others and practices varied significantly in how they had implemented the approach. CONCLUSIONS: The 'telephone-first' approach appears to work well for some patients, but others find it much less acceptable. Some of the reported problems related to how the approach had been implemented rather than the 'telephone-first' approach in principle and suggests there may be potential for some of the challenges experienced by patients to be overcome.National Institute for Health Researc

Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment

This is the final version of the report. Available from the publisher via the DOI in this record.BACKGROUND: Available evidence on effective interventions to reduce length of stay in hospital is wide-ranging and complex, with underlying factors including those acting at the health system, organisational and patient levels, and the interface between these. There is a need to better understand the diverse literature on reducing the length of hospital stay. OBJECTIVES: This study sought to (i) describe the nature of interventions that have been used to reduce length of stay in acute care hospitals; (ii) identify the factors that are known to influence length of stay; and (iii) assess the impact of interventions on patient outcomes, service outcomes and costs. DATA SOURCES: We searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium and System for Information on Grey Literature in Europe for the period January 1995 to January 2013 with no limitation of publication type. METHODS: We conducted a rapid evidence synthesis of the peer-reviewed literature on organisational interventions set in or initiated from acute hospitals. We considered evidence published between 2003 and 2013. Data were analysed drawing on the principles of narrative synthesis. We also carried out interviews with eight NHS managers and clinical leads in four sites in England. Results: A total of 53 studies met our inclusion criteria, including 19 systematic reviews and 34 primary studies. Although the overall evidence base was varied and frequently lacked a robust study design, we identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings. LIMITATIONS: We only considered assessments of interventions which provided a quantitative estimate of the impact of the given organisational intervention on length of hospital stay. There was a general lack of robust evidence and poor reporting, weakening the conclusions that can be drawn from the review. CONCLUSIONS: The design and implementation of an intervention seeking to reduce (directly or indirectly) the length of stay in hospital should be informed by local context and needs. This involves understanding how the intervention is seeking to change processes and behaviours that are anticipated, based on the available evidence, to achieve desired outcomes (‘theory of change’). It will also involve assessing the organisational structures and processes that will need to be put in place to ensure that staff who are expected to deliver the intervention are appropriately prepared and supported. With regard to future research, greater attention should be given to the theoretical underpinning of the design, implementation and evaluation of interventions or programmes. There is a need for further research using appropriate methodology to assess the effectiveness of different types of interventions in different settings. Different evaluation approaches may be useful, and closer relationships between researchers and NHS organisations would enable more formative evaluation. Full economic costing should be undertaken where possible, including considering the cost implications for the wider local health economyThe National Institute for Health Research Health Services and Delivery Research programme

Probiotics and urogenital infections: a protocol for an evidence and gap map

This is the final version.Urogenital infections, particularly bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and urinary tract infections (UTI), are routinely treated with antibiotics. However, there are mounting concerns about the need for alternative or adjunct therapies due to increasing antimicrobial resistance. Probiotics have garnered significant interest both in the scientific community and the public. This is due to their ability to compete with pathogens, hindering their colonization and contributing to host defence mechanisms. However, their effectiveness in the management of urogenital infections in clinical and primary care settings have been inconsistent across clinical studies and systematic reviews. This evidence and gap map (EGM) seeks to offer comprehensive and clearer overviews of probiotics in relation to urogenital infection management. This method ensures an unbiased evaluation of the present body of evidence on probiotic use, consolidating the existing knowledge and identify the knowledge gaps which can inform research, clinical decision-making and healthcare practice policy development